Healthcare Provider Details

I. General information

NPI: 1760589287
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL ASSOCIATES P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202-A BEECHMONT ROAD
SOUTH BOSTON VA
24592-2547
US

IV. Provider business mailing address

2202-A BEECHMONT ROAD
SOUTH BOSTON VA
24592-2547
US

V. Phone/Fax

Practice location:
  • Phone: 434-575-6300
  • Fax: 434-575-8300
Mailing address:
  • Phone: 434-575-6300
  • Fax: 434-575-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number010141405
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101023654
License Number StateVA

VIII. Authorized Official

Name: DR. SHERRY LENE HALL
Title or Position: M.D
Credential: M.D
Phone: 434-575-6300